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May 4th’s Health Affairs contains a lot of food for thought for Geriatricians and Palliative Care providers thinking about the future of medicine and health care reform.

“A Case of Medical Homelessness” by Dr. Jack M. Colwill (full disclosure, my former chair) sounds like a typical case for any palliative care provider. A patient with advanced emphysema, John--the brother-in-law of the author, doesn’t respond to therapies and becomes progressively weaker, with dyspnea and anxiety. Visits to primary care, a pulmonologist, an interventionalist to drain an effusion do not relieve his symptoms. Then, despite dramatic decline over the next half year, John undergoes surgery for his hand just two months before his death and has a complete set of dentures made (that continue to require payments after his death.) In all 11 doctors were seen, and yet the family felt abandoned. It took a visit from the author/brother-in-law/MD to finally address the issue of advanced directives and prognosis and to reframe care to face the fact that the patient was dying. Finally, hospice came in and saved the day.

The patient was adrift in a complex system, and no physician assumed the responsibility of care coordination. Colwill attributes medical homelessness to what Diane Meier has called “the Original Sin of Medicare” where financial incentives are misaligned as payments are made for numbers of visits, as opposed to outcomes. Furthermore, the shortage of primary care physicians create impossible work load demands that prevent true coordination of care. Dr. Colwill concludes that what is needed is a Patient-Centered Medical Home (PCMH). And I think that we could also add Palliative Medicine was needed earlier!!

The entire issue goes on to address Reinventing Primary Care. For fans of podcasting listen to Annals of Internal Medicine’s May 18, 2010 podcast (at approximately the 11th minute and 10 seconds mark) to hear why the primary care workday should be reinvented to manage more disease by phone and email (and get paid). Then listen to the experience of transition to a PCMH for one health system, and finally hear an experience with electronic referrals.

In the print edition, the history of primary care is reviewed, and an evidence base for the value of primary care is presented. Seven articles explore the Medical Home concept as a solution, including an overview of the experience of Group Health of Seattle moving to the Medical Home. Other articles address the role of teams including articles addressing the importance of Physician Assistants, Nurse Practitioners, and Pharmacists in the Medical Home concept. (Shocking news to the Geriatricians and PC providers!) Articles on patient perspectives on PCMH as well as payment structures for the PCMH concept follow. Phillips and Bazemore argue that to be on par with other developed nations, the United States should double the current investment in primary care to 10-12% of health care expenditures, and make the point that the reduction in total health care costs would make up for the investment.

Geriatricians (and I would argue PC providers too) will be especially interested in “The Urgency of Preparing Primary Care Physicians to Care for Older People with Chronic Illnesses” by Chad Boult, Steven Counsell, Rosanne Leipzig and Robert Berenson. They describe 3 choices for the future of geriatrics: 1. Continue the status quo, training modest numbers of fellows and hope that they revitalize the discipline-a choice they describe as doomed to fail. 2. Redouble existing efforts to recruit more fellows- another pathway to failure they conclude. 3. Reinvent geriatrics as a discipline of geriatrician leaders/educators who train many disciplines in geriatric principles and train the trainers within that discipline to become geriatric experts within their field. In particular, geriatricians must train primary care physicians to provide higher quality and more cost-effective care to older people with multiple chronic conditions. They make the point that for this model to work the US must increase the primary care work force, pay adequately for high-quality chronic care, and develop cost-effective modes of chronic care. Palliative care providers can think of this as the concept of Primary, Secondary, and Tertiary Palliative Care.

I think the Boult et. al. article is especially important for both Geriatric Medicine and Palliative Medicine. Despite all of the gains that are made in academic and urban settings, the aging rural population will depend on a good primary care doctor who has the skills to practice both geriatric medicine and palliative care and coordinate care. What have you done to help educate that primary care doc lately??

By: Paul Tatum

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Terrific summary and commentary Paul. As you note, we've been working in teams sucessfully in Geriatrics and Palliative Care for some time...nice of the patient centered medical home folks to catch on! I'm still trying to work out how Geriatricians and Palliative care docs work within the PCMH. Advisors to practices, and open to referalls for complex cases, yes, but does it also mean a change in the structure of our outpatient practices? Can we be more PCMH-like than we already are?

I appreciated this post, and look forward to reading the HealthAffairs issue. I agree that key issues are how to build capacity in primary care and develop 'shared care' models in which geriatrics and palliative care specialists, among others, can work efficiently with primary care. The UK has made a determined effort in this regard via its Gold Standards Framework - For a Canadian example, see “Enhancing family physician capacity to deliver quality palliative home care. An end-of-life, shared-care model.” Marshall, et al. Can Fam Phys 2008. Paul McIntyre, Halifax, Canada

Thanks, Alex. I can't remember where, but Diane Meier posted an interesting discussion on her Twitter recently about whether specialists could be part of the PCMH. If anyone should be, Palliative care should.I think of the PCMH as coordination of care for people with complex medical illnesses. That is Palliative Medicine!

For anonymous: 2 more articles within the May Health Affairs issue to look at: Find the section Lessons From Abroad Lessons From Major Initiatives To Improve Primary Care In The United KingdomTim Doran and Martin Roland

Reinventing Primary Care: Lessons From Canada For The United StatesBarbara Starfield

Given the $ spent and outcomes achieved there is clearly lots the US can learn from other systems.

paul-great placement of this article on the geripal nexus. outpatient palliative care, where it can be done well and serve a community, as a specialty care/primary care hybrid, given the values of palliative care, really is a patient-centered medical home model. it is not common yet. for the future, i think each internist, geriatrician, family doc, oncologist, cardiologist, etc. needs to think about do they really want to do this in their practice for their sickest and declining patients. if so, and they can hire the staff and have the shared team training to do it, then they should do it. if they want a palliative care team to help them with some of their patients, then that is another way to provide the care needed in fine fashion. the PC does this kind of care for all their patients, not just for the sick ones who want to avoid the hospital, because that is all of our patients! it takes a lot of time and work to do this kind of care, and it is not a get rich quick scheme for sure!thanksclay

Thanks Paul for the great summary of these articles. Sounds like a whole tutorial on health policy in one issue.

I'll look forward to reading the article about primary care and Geriatrics. I understand why the authors are discouraged about training enough Geriatricians. There do not seem to be easy answers to this problem. So, on the one hand viewing Geriatrics primarily as a specialty that trains other health professionals to care for frail elders makes sense. This certainly is an important role for the specialty, and this seems to be a recommendation we frequently hear. However, I have also not heard convincing evidence that this will be a viable model for the discipline. Can a specialty really thrive as a primarily academic discipline? Is there any precedent for believing this type of model can succeed?

Excellent idea that must include palliative and hospice care to best serve all. I would also like to suggest that medical social work be given a place in this home as well due to the multitude of psychosocial issues that arise in geriatrics and end of life scenarios.The medical home might be a good answer for those patients who fall into the grey zone of not wanting aggressive care, or a return to the hospital, but not quite meeting Medicare criteria for hospice. We have many patients who come onto hospice, do better (often due to the increased attention and oversight) only to no longer qualify, thus having to be discharged from service, only to return to that no man's land of the regular health care system. All too often they have an event of some kind, return to service only to then die quickly.I'm glad this is being discussed and considered.Linda

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